New Patient Intake, Consent, Information Form- Referral (Intralipid + Iron)

New Patient Intake, Consent & Information Form

Intralipids, Fluids & Iron
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Intralipid Treatments, and Iron Infusions can only be administered with a completed referral form. Please organise a signed referral form from your GP, fertility specialist, or another qualified medical practitioner prior to your appointment.

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Essential Patient Information

Payment & Appointment Preparation
- Payment: Full payment is required before your treatment. We accept Visa, MasterCard, and EFTPOS. Cash payments are not accepted.
- Comfort: We recommend bringing a jumper , shawl or scarf in case you feel cold during the infusion.
- Children: To ensure a safe, comfortable, and relaxing experience for all our patients, we kindly ask that children not accompany you to your appointment, as we do not have facilities for their supervision. Thank you for your understanding and cooperation.
- Accompanying Persons: To ensure patient privacy, anyone accompanying you will need to remain in the waiting area or be in your allocated treament room.
- Clothing: Please wear loose-fitting clothing with sleeves that can be comfortably rolled above the elbow for IV insertion.
- Hydration & Food: Please ensure you have eaten and are well-hydrated before your appointment. Proper hydration helps with IV placement and overall comfort.
- Medical Conditions: If you have a heart or kidney condition, please consult your doctor about your required hydration level before the infusion.
Iron Infusions

Important Information - ***Intravenous iron is safe for use after 16 weeks of pregnancy, but please consult your doctor to discuss the benefits and risks*** These infusions are not covered by medicare and are an out of pocket expense.
Why Iron is Important:
Iron is essential for your body’s muscle function, oxygen transport, and red blood cell production. Iron deficiency can lead to:
- Fatigue, weakness, dizziness, or shortness of breath.
- Poor concentration and pale complexion.
- In pregnancy, iron deficiency may affect fetal growth and result in low birth weight.
If prescribed an iron infusion, this means your doctor has determined that oral iron supplements are not sufficient or not suitable for you.

The Iron Infusion Process:

Medication: Your infusion will contain an iron-based medication such as Ferinject® or Monofer®.
Administration: The infusion typically takes 15 to 30 minutes, followed by additional IV hydration over another 30 minutes to reduce side effects.
Number of Infusions: Some patients may require more than one infusion for full treatment, depending on their iron levels.
Potential Side Effects: Most side effects are mild and uncommon, including:
- Flu-like symptoms (fever, chills, headache).
- Nausea or dizziness.
- Muscle or joint aches.
- Low blood pressure (rare).
Rare Complications: If the IV cannula dislodges, iron may leak into the surrounding tissue, causing permanent skin staining. The risk of this is less than 1 in 1000 patients. Severe allergic reactions (anaphylaxis) are also very rare. Our trained nurses are fully prepared to manage any unexpected reactions.

I have read the the QLD Government Iron Infusion Information Pack.
Intravenous (IV) Infusions

What to Expect
IV infusions allow for the direct administration of fluids or medications into your bloodstream. This is done through a small intravenous (IV) cannula, inserted by a trained nurse or midwife into a large vein, typically in your forearm.

Procedure:
1. A tourniquet is applied to locate a suitable vein.
2. A small plastic cannula is inserted into the vein using a sterile needle.
3. The needle is removed, leaving only the flexible cannula for medication or fluid administration.
4. The tourniquet is released, and a dressing is applied to secure the cannula.
5. The prescribed medication or fluid is attached and infused over the required time.
6. Once completed, the cannula is removed, and pressure is applied to stop any bleeding.
Common Side Effects:

Mild bruising, irritation, or tenderness at the site for a few days. There is are small risks of infection with any medical procedure. Please monitor the site for redness, swelling, or pain over the next seven days. If these symptoms occur, please seek medical attention immediately.

Informed Consent (For Treatments requiring a referral i.e, Intralipid & Iron Infusions)
I First Name* Last Name* acknowledge and consent to receiving treatment at The Infusion Centre Name. I confirm that my referring doctor or clinician has explained my medical condition, the proposed treatment, and the general and specific risks and benefits associated with this treatment, including but not limited to allergic reactions, bruising at the injection site, vein irritation, discomfort, and, in rare cases, more serious complications. I understand that results may vary between individuals, and no guarantees have been made regarding specific outcomes. I understand that it is my responsibility to discuss any concerns or questions with my referring doctor or clinician before proceeding.

I voluntarily consent to receive the recommended treatment and acknowledge that I have had the opportunity to make an informed decision. I also understand that I have the right to withdraw my consent at any time, including after signing this form, by notifying the treating healthcare provider.

By signing this form, I confirm that I have read and understood the information provided and that I agree to proceed with treatment under these term
Patient Acknowledgement & Consent
Please review the statements below and tick the boxes to confirm your agreement:*

Iron Infusion Patients Only – I confirm that I have read and been provided with the QLD Government Iron Infusion Information Pack (link above)Consent for Recording – I consent to staff or contractors taking video, audio, or images during my procedure when such recording is not required for treatment but may be used for training or research purposes.Consent for Recording – I consent to staff or contractors taking video, audio, or images during my procedure when such recording is not required for treatment but may be used for marketing purposes.Medical Disclosure – I have disclosed all known allergies, medical conditions, and medications I am currently taking. I understand my responsibility to inform the healthcare provider of any changes in my health status before receiving the infusionInformed Discussion – I have had the opportunity to ask questions and raise concerns with my doctor or clinician about the proposed treatment.Right to Withdraw – I acknowledge that I have the right to refuse or discontinue treatment at any time, including after signing this formAdverse Reactions – I understand that if I experience any adverse reactions, I must inform the Infusion Centre staff immediately or, if outside the clinic, seek medical attention from my doctor.Liability Release – I release The Infusion Centre Name, its staff, and affiliated professionals from any liability related to my participation in this treatment, except in cases of negligence or misconduct.
Patient Signature*

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Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Nurse/Midwife Signature

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Nurse/Midwife Name

First NameLast Name
Date

MonthDayYear
Date
The Infusion Centre

306 Olsen Avenue

Parkwood, QLD 4214

+61 449 916 829

info@theinfusioncentre.com.au
Should be Empty:

	Yes	No	Remarks
Are you pregnant? *if so wks gestation
Do you have any known allergies? *If yes please outline below.
Do you suffer from heart, kidney conditions * If YES- please ask your doctor for guidance on the appropriate amount of hydration prior to the infusion/ treatment.

New Patient Intake, Consent & Information Form

Current Medical Status

Essential Patient Information

Iron Infusions

Intravenous (IV) Infusions

Informed Consent (For Treatments requiring a referral i.e, Intralipid & Iron Infusions)

Patient Acknowledgement & Consent